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Healing Touch Intake Form
Please fill out this form so that Eve can have some additional information to help her with your session(s).
Feel free to leave blank any questions you don't feel comfortable answering
. All information will be kept confidential.
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* Indicates required question
Email
*
Your email
What is your
last name
?
*
Your answer
What is your
first name
?
*
Your answer
What is your
email address
?
*
Your answer
What is your
phone number
? Is this a cell or landline?
*
Your answer
What is your
address
? (please include street, city, state, & zip code)
*
Your answer
Emergency Contact
(name and phone)
*
Your answer
What is your
Date of Birth
?
Your answer
Living Situation
(Marital Status/pets; home as supportive or stressful? Social, family, personal support?)
Your answer
Military Branch
and years
Your answer
What is your current job/employment?
Your answer
What change would you like to see in yourself as a result of this session?
Your answer
Prior Energy Therapy/Healing Touch Experience?
Your answer
Spiritual Beliefs/Practices/Affiliations?
Your answer
Is your belief a source of support to you?
Yes
No
Clear selection
Word/Name you use for Higher Power?
Your answer
Current Self-Care Practices
(exercise, mediation, relaxation, body care, journaling, etc):
Your answer
Rate yourself from 1 to 10 (10 being an extreme issue/concern) for each of the items below.
Personal Relationships
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Physical Health
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Mental Health
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Emotional Health
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Spiritual
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Work
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Finances
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Eating/Nutrition
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Addiction
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Depression
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Mood Swings
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Anger
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Anxiety
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Panic or Anxiety Attacks
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Trauma/PTSD
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Memory Problems
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Personal Direction
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Headaches
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Pain
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Fatigue/Lethargy
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Hormonal Issues
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Allergies
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Sleeping Issues
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Safety
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Major Life Changes
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Other
Little to No Concern
1
2
3
4
5
6
7
8
9
10
Extreme Concern/Issue
Clear selection
Please describe any items rated at 7 or higher.
Your answer
Relevant Health History
Current overall health condition
Excellent
Very Good
Good
Fair
Poor
Clear selection
To what do you attribute your current situation, symptom, or health issue?
Your answer
Is there anything else you want me to know? Any questions about me or Healing Touch?
Your answer
Thank you for filling out the Intake Form. This information will be kept confidential.
A copy of your responses will be emailed to the address you provided.
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